COVID-19 could lead to 500,000 excess HIV-related deaths in sub-Saharan Africa linked to interruptions in ART supply

COVID-19 associated disruptions to HIV services could lead to over 500,000 excess adult deaths and approximately double the rate of vertical transmission – according to modelling published ahead of print 11 May 2020. [1, 2]

Investigators from the HIV Modelling Consortium set out to predict the potential effects of disruptions associated with the COVID-19 epidemic on HIV-related deaths and new infections.

They combined results from five independent models of HIV epidemics (Goals, Optima HIV, HIV Synthesis, an Imperial College London Model and EMOD) to estimate the effect of various potential scenarios on HIV treatment and prevention services.

Unsurprisingly, disruptions to all aspects of HIV care were associated with increases in mortality risks. Most importantly interruptions to the supply of ART leading to treatment discontinuation.

The modelling predicted that 6-months interruption of ART supply across the HIV population could lead to approximately 2-fold increase in mortality risk (from 1.87- to 2.80-fold across models) over a one year period compared with no disruption.

There was also an effect predicted in the years following the 6-month disruption of around 40% (35% to 41% across models) excess death for each of the next five years.

In countries and regions in sub-Saharan Africa this suggested an excess of over 500,000 (range: 471,000 to 673,000) excess HIV deaths following the 6-month disruption.

A more sporadic interruption of ART supply (across only a proportion of the population or for a shorter time) would have less effect on mortality: 1.05- and 1.17-fold increase compared with current annual deaths for a 3- and 6 month interruption respectively (1.00- and 1.03-fold increase over 5 years).

The authors noted that even in a scenario with largely dolutegravir-based ART, interruptions would lead to an increase in drug resistance and a 1% lower proportion of people with undetectable viral load in the next 5 years.

An interruption in the supply of cotrimoxazole was predicted to result in an increase in HIV mortality of 8% over one year.

Stopping maternal/infant HIV activities could lead to significant increases in the number of vertical infections: 78% Malawi, 37% Mozambique, 104% Uganda and 78% Zimbabwe. The impact of ART interruption on vertical transmission was predicted to be an excess of 1.67 and 2.07 times more babies born with HIV in one year as a result of 3 and 6 months disruption, respectively.

Disruption to outreach and condom programmes could lead to increases in new HIV infections of up to 25% a year. PrEP programmes are currently small in most settings but a 6-month disruption was predicted to lead to a 1% rise in HIV incidence over one year.

The authors concluded that, when considering plans to manage the effects of the COVID-19, it is critical that governments, donors, suppliers and communities focus on maintaining the supply of ART for people with HIV to avoid excess deaths, and the provision of other prevention strategies to stop any increase in HIV incidence.